Journal of Traumatic Stress Disorders & Treatment ISSN: 2324-8947

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Case Report, J Trauma Stress Disor Treat Vol: 5 Issue: 1

The Diagnosis and Treatment of Pancreas Injury: A Report of 26 Cases

Chen Tianjin1, Gao Hong2, Wei Zhangying1, Mu Dean2, Gong Jianping2 and Guo Can1*
1Department of Emergency Surgery, Chongqing Three Gorges Central Hospital, Wanzhou-404000, China
2Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing-400010, China
Corresponding author : Guo Can
Department of Emergency Surgery, Chongqing Three Gorges Central Hospital, Wanzhou 404000, China
Tel: +86-13996286589, Fax: +86-23-63829191
E-mail: [email protected]
Received: December 10, 2015 Accepted: February 16, 2016 Published: February 20, 2016
Citation: Tianjin C, Hong G, Zhangying W, Dean M, Jianping G, et al. (2016) The Diagnosis and Treatment of Pancreas Injury: A Report of 26 Cases. J Trauma Stress Disor Treat 5:1. doi:10.4172/2324-8947.1000153

Abstract

The Diagnosis and Treatment of Pancreas Injury: A Report of 26 Cases

Objective: To investigate the diagnosis and treatment of pancreatic injury.
Methods: A retrospective analysis of 26 patients with pancreatic injury was performed.
Results: According to the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST), there were12 in grade I, 7 in grade II, 4 in grade III, 2 in grade IV, 1 in grade V. In 26 patients, proximal pancreatic suture and distal pancreatectomy were performed in 2 cases; proximal pancreatic suture and distal pancreatic-jejunum Roux-en-Y anastomosis were performed in 4 cases, pancreatic head-jejunum Roux-en-Y anastomosis were performed in 2 cases, simple pancreas repair in 8 cases and simple pancreas drainage were performed in 10 cases. 24 patients were cured and 2 died in the end.
Conclusion: Early diagnosis of pancreatic injury is difficult and early surgery should be done once the injury is suspected. Depending on the grade of pancreatic injury, the surgical management including drainage, nutrition after operation is very important.

Keywords: Pancreas injury; Diagnosis; Treatment

Keywords

Pancreas injury; Diagnosis; Treatment

Introduction

Pancreatic injury is an uncommon life-threatening injury accounting for 4% of the abdominal trauma [1]. Due to the different point and direction of trauma, the head, body and tail of pancreas may be injured alone or together [2,3]. The mortality of pancreatic injury is about 28%, when combined with duodenum injury; it can reach up to 40%-50% [4]. Meanwhile, a series of severe complications may emerge after the injury. Here is a retrospective analysis of 26 patients with pancreatic trauma focused on the diagnosis and treatment of pancreatic injury is discussed mainly.
Clinical data
26 patients including 15 males and 11 females admitted by the Second Affiliated Hospital of Chongqing Medical University from 2003 to 2012 were included in this study. Patients’ age ranged from 9 to 61 years old. 19 patients were diagnosed with closed abdominal injury including 17 traffic injury and 2 falling injury; the rest 7 were open abdominal injury including 6 stab wound and 1 is gun-shoot injury. The duration between trauma and surgery ranged from 80 minutes to 2 days. All patients had different degree of abdominal pain, in which 16 manifested internal hemorrhage and 10 showed peritonitis mainly. Varying degrees of shock existed in internal bleeding patients and the blood pressure was (0∼90)/(0∼60)mmHg. Diagnostic abdominal puncture is carried out in all patients before operation and all of them had positive results. Amylase test of peritoneal fluid in 18 patients was performed before surgery, in which 10 were positive later proved pancreatic duct disruption during operation. 2 pancreatic injuries were found in 10 patients undergoing the ultrasound examination, while 10 pancreatic injuries were discovered in 16 patients who did CT scan (diagnosis ratio 20% versus 62.5%).

Results

All 26 cases were proved to have different degree of pancreatic injury by emergency surgery including 5 pancreatic head injuries, 15 body injuries and 6 tail injuries. According to the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST) in Table 1, there were 12 in grade I, 7 in grade II, 4 in grade III, 2 in grade IV, 1 in grade V (Figure 1). Only 2 cases were single pancreatic injury and the remaining 24 patients had other organ injury (Figure 2). In these 24 patients, 14 combined with one organ injury and 10 combined with 2 or more organs. The viscera of associated injury includes duodenum injury (2 cases), liver injury (5 cases), spleen injury (4 cases), gastrointestinal perforation (1 case), right renal laceration (1 case), craniocerebral injury (2 cases), thoracic injury (3 cases), and extremity or trunk fracture (4 cases) (Figure 3). On the basis of different conditions, we chose different surgical procedures respectively. Including proximal pancreatic suture + distal pancreatectomy (2 cases), proximal pancreatic suture + distal pancreatic-jejunum Roux-en-y anastomosis (4 cases), pancreatic head-jejunum Roux-en-y anastomosis (2 cases), simple pancreas repair (8 cases) and simple pancreas drainage (10 cases). Post-operation complications were observed in 8 patients including pancreas fistula(2 cases), stress ulcer(2 cases), incision infection(3 cases) and lung infection(1 case). 24 patients were cured while other 2 patients both died of craniocerebrala injury accompanied by brain herniation. No intestinal fistula took place in 6 patients undergoing pancreaticojejunostomy.
Table 1: Pancreas Injury Scale.
Figure 1: Pancreas injury grade of 26 patients
Figure 2: Injury classification of 26 patients.
Figure 3: Injury location of 26 patients.

Discussion

Basic features of pancreatic injury
Pancreas is a retroperitoneal organ located in the epigastric and left hypochondriac regions at the levels of lumbar 1-2 spine. Because it is closely adjacent to multiple abdominal viscera and large blood vessels, a single pancreatic injury is uncommon. About 90% cases are combined with associated intra-abdominal injuries [1]. All but 2 of 26 patients in our series have associated intra-abdominal injuries, which confirm that isolated pancreatic injury is rare. Chinnery et al. reported that 3 associated injured organs per patient in patients with pancreatic injury [5]. Besides, due to the different reasons of injury non-abdominal injuries are found sometimes and the head, chest, extremities are the most common non-abdominal parts in associated injuries [6].
Etiology of pancreatic injury
Pancreatic injury can be attributed to penetrating or blunt abdominal trauma. About 20%-30% patients with penetrating trauma caused by stab and gunshot wounds have pancreatic injury; Due to the thinner layer of protective fatty tissue in the retroperitoneal area, blunt injuries caused by a sudden localized force to the upper abdomen compressing pancreas against the rigid spinal column are often found in children and young adults [7]. In 7 patients with penetrating pancreatic injury of our data, 6 patients were caused by stab wounds and 1 by gunshot wounds while 17 traffic injuries and 2 falling injuries were included in 19 blunt injuries.
Diagnosis
Pancreatic injury is usually difficult to recognize due to its location and non-specific symptoms and signs. In open abdominal injury, especially for ballistic injury, pancreatic injury usually accompanies with viscera and blood vessel injury. Pancreatic injury can be preliminary judged by the ballistic inlet and outlet and the effluent from wound (containing pancreatic juice, bile or not). It is difficult to recognize the blunt pancreatic injury before operation, particularly when it comes to single pancreatic injury, because it shows subtle symptoms and signs of abdomen at early stage due to its retroperitoneal location. Therefore, comprehensive examinations are required to detect that if there exists a pancreatic injury in the upper abdominal injury, especially for the coup injury.
In addition, early abdominal puncture is necessary for early diagnosis. Once positive result discovered, the amylase test should be done sequentially and dynamically. However, the correlation between elevated amylase and pancreatic trauma is relatively poor [7]. In this study, amylase of peritoneal fluid was tested in 18 patients before surgery and 10 were positive later proved to be the fracture of pancreatic duct. A dynamic observation of serum amylase is helpful in some way as well however published data on the value of serum amylase in patients with abdominal trauma have shown mixed results [8-11]. Mahajan et al. find continuous elevation or rising combined with serum amylase and lipase levels are reliable time-dependent indicators of pancreatic injury butit has no diagnostic value within 6 h or less after trauma [12].
Although ultrasound is simple and practical however its diagnostic ratio is relatively low because it is easily interfered by the air in gastrointestinal tract [13]. In our cases, the positive rate is only 20%. Contrast-enhanced ultrasound (CEUS) can provide a reliable diagnosis for blunt pancreatic injury compared with common ultrasound. In CEUS, site of pancreatic injury manifested as anechoic and/or hypoechoic perfusion defect region with irregular borders in both the arterial and parenchymal phases [14].
Computed tomography (CT) is usually done in patients with closed abdominal trauma to detect intra-abdominal organs injury. CT imaging findings of pancreatic injury including low attenuation fluid, hyper attenuating peripancreatic fluid, pancreatic contusion, active hemorrhage and pancreatic laceration [15]. Wong YC et al reported the sensitivity of thin section CT scans is 91% [16] and the positive rate is 62.5% in our cases. Thus, computed tomography (CT) is the modality of choice in hemodynamically stable patients with blunt abdominal trauma. But initial CT scan findings of patients with pancreatic injuries may be negative within the first 12h after injury [17]. As an invasive procedure, Endoscopic Retrograde Cholangiopancreatography (ERCP) can show the structure of pancreatic duct and now it is recognized as the golden standard of diagnosing pancreatic duct injury. For patients with mild symptoms or signs, ERCP can be used to evaluate the integrity of pancreatic duct before surgery as well. Sometimes it can also act as a treatment (e.g. pancreatic sphincterotomies, pancreatic ductal stenting) instead of laparotomy including [18,19]. But it is inapplicable to preoperative assessment in critical patients due to its complexity and timeconsuming. Magnetic resonance cholangiopancreatography (MRCP) as a non-invasive examination can be applied for the patients in stable condition has high accuracy in assessing the integrity of the pancreatic duct as well [20].
Patients with pancreatic injury often combine with injury of other organs or tissue. It is reported that the morbidity of closed pancreatic trauma accompanied with other abdominal viscera injury is about 58%-73% [21]. Because of the critical condition when admitted, it is necessary to conduct exploratory laparotomy for those with indications as early as possible. However, pancreatic injury or retroperitoneal duodenum perforation might be missed during laparotomy and misdiagnosis rate of perforation is reported as 24%- 30%. Pancreatoduodenal injury should be highly suspected when some situations are found intra-operation: bloody or brown fluid in abdomen and unknown sources of bleeding; fat saponification on omentum or mesentery; transverse colon contusion or hematoma in the mesenteric root; hematoma from retroperitoneum or paraduodenum; bile dyeing or pneumatosis. Under such circumstances, a comprehensive and careful inspection of pancreas and duodenum needed to be done so as to avoid misdiagnose. When hematoma in front of pancreas is detected, it is indispensable to dissociate pancreas for afterwards checking. Through this procedure we can judge the degree of injury and check whether the main duct injury exists.
Management
The therapeutic principles of pancreatic injury are as follow: debridement, hemostasis, normal anatomic structure recovery, pancreatic juice leakage control, sufficient drainage, associated damages treatment and postoperation nutrition support [22,23]. The choose of surgery types depends on the damage situation and systemic conditions of patients.
Grade I-II: The surgical procedures include stopping bleeding, suturing and drainaging in lesser peritoneal sac after hematoma removed. In our data, 19 cases were treated with mentioned methods and 10 cases were cured by simple peripancreatic drainage for that most pancreatic fistula would heal itself by fully draining.
Grade III-V: Proximal pancreatic suture + distalpancreatectomy + splenectomy are the proper surgical procedures for their simplicity and have few complications [24]. Mostly, if resecte the left mesenteric vessel part of pancreas, no endocrine or exocrine insufficiency would occur after operation. But insufficiency would take place (type I diabetes mellitus) if distal pancreatectomy is performed on the right side of mesenteric vessel [25]. Therefore, we suggest proximal pancreatic suture+distal debridement+distal pancreatic-jejunum Roux-en-y anastomosis when pancreas fractures on the right of mesenteric vessel and debridement+ pancreatic-jejunum Roux-en-y anastomosis in head lacerating and the duct disrupting. To avoid anastomotic fistula, it is important to highlight the follows: debride and prevent bleeding thoroughly before anastomosis; suture the first layer without crossing pancreatic parenchyma when preventing pancreatic juice extravasating; do the pressure test after anastomosis which means using a forceps clips the distal of jejunum, injecting saline from the proximal to create continuous pressure and watching if there is any leakage around anastomosis. 8 cases in our group were performed with these types of operation and no pancreatic leakage or abdominal infection was observed after surgeries.
When immediate life-threatening situations (hemodynamic instability, acidosis, hypothermia and coagulopathy or severe complex pancreaticoduodenal trauma) exists, initial damage control surgery (DCS) should be performed in the first place and reconstruction should not be considered unless vital signs become stable [26-29].
Drainage: pancreatic injury (especially for grade III or above) leads to massive inflammatory exudates in abdomen or retroperitoneum due to the stimulation of large amount of pancreatic and duodenal juice. Besides, surgical trauma is also an indispensable factor. As a consequence, fully and effectively drainage of abdomen and peripancreatic space is vital for wound healing and preventing various complications [30]. During operation, carefully adjust the location of stomach into duodenum is the best option and post-operation daily drainage volume and level of amylase in drainage are noteworthy. The right time to remove the tube is when drainage decreases obviously and amylase in drainage recover to normality. In our cases, doubletube was applied with both negative pressure draining locating in the superior and inferior of pancreas, paraduodenum and pelvic cavity. During the laparotomy of one stab wound, multiple injuries including right renal and liver laceration, penetrating wound of duodenum, rupturing of pancreatic head and disrupting of the main pancreatic duct were found. The managements of this case included debridement, injured organs repair and pancreatic-jejunum Rouxen- y anastomosis. A gastric tube also placed the in duodenum for 12 days and no intestinal fistula, pancreatic fistula or wound infections were found after surgery.
Nutrition
Most trauma patients consume energy severely under stressed state. Besides, extensive inflammatory effusion in abdomen, long time fasting and gastrointestinal decompression results in vast loss of body nutrients. Therefore, appropriate nutrition support is another crucial factor affecting prognosis. All patients in our cases received total parenteral nutrition for one week after surgery meanwhile plasma and albumin were provided simultaneously. These can inhibit the secret of pancreas, prevent pancreatic-jejunum anastomotic fistula and some other complications and are benefit for the recover from the trauma and inflammation.
Complication
Complications after pancreatic injury can be divided into two categories: pancreas-related complications (e.g. fistula, pseudocyst, intraabdominal abscess) and systemic complications (e.g. ARDS, pneumonia, renal failure, sepsis) [31]. Herman et al. found that higher level of amylase was highly predictive for developing a pseudocyst [9] and others reported non-operative management of pancreatic injuries was associated with increases in complications [30,32]. 8 patients with complications were found in our group, covering 2 pancreatic fistulas, 3 wound infections, 1 lung infection and 2 stress ulcers and they were all treated properly and immediately. A much better prognosis can be obtained with appropriate application of somatostatin, parenteral nutrition and anti-infection therapy meanwhile keeping fully well drainage.

Summarize

Early diagnoses of pancreatic trauma is difficult, it often involves associated injury and has high incidence of complications. In order to acquire a comprehensive assessment, history collection, early abdominal puncture and imageology examination are all of great importance. Main pancreatic duct condition is important to guide management and choose of surgery types depends on the damage situation and systemic conditions of patients. In a word, reducing complications and lowering mortality depend on early diagnose, appropriate operation, fully drainage and comprehensive postoperation management.

Conflict of interests

The authors declare they have no conflict of interests.

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